Joint arthrodesis and arthroplasty

ABSTRACT

An implantable fixation system for fusing a joint between a first bone and a second bone. The system may include an anchor, standoff, bolt, and cortical washer. The system may be implanted across the joint along a single trajectory, the length of the system adjustable to provide compressive force between the anchor and the cortical washer. The system may be implanted across a tibiotalar joint with the anchor positioned in the sinus tarsi. A spacing member may be inserted between the two bones and the fixation system implanted to extend through an opening in the spacing member. The spacing member may be anatomically shaped and/or provide deformity correction. An ankle arthroplasty system may include a tibial plate, a talar plate, and a bearing insert. The plates may be anchored to the tibia and talus along a single trajectory. The ankle arthroplasty system may be revisable to a fusion system.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of pending U.S. patent applicationSer. No. 13/964,945, filed Aug. 12, 2013, and is entitled JOINTARTHRODESIS AND ARTHROPLASTY, which is a continuation of:

U.S. patent application Ser. No. 12/835,032, filed Jul. 13, 2010, nowpatented as U.S. Pat. No. 8,585,744, and is entitled JOINT ARTHRODESISAND ARTHROPLASTY.

U.S. patent application Ser. No. 12/835,032 claims the benefit of thefollowing:

U.S. Provisional Patent Application No. 61/225,398, filed Jul. 14, 2009,and is entitled MODULAR ANKLE HEMIARTHROPLASTY;

U.S. Provisional Patent Application No. 61/254,500, filed Oct. 23, 2009,and is entitled SYSTEMS AND METHODS FOR ANKLE REPLACEMENT, ANKLE FUSIONAND HINDFOOT FUSION;

U.S. Provisional Patent Application No. 61/254,512, filed Oct. 23, 2009,and is entitled SYSTEMS AND METHODS FOR WRIST ARTHROPLASTY AND WRISTFUSION;

U.S. Provisional Patent Application No. 61/323,156, filed Apr. 12, 2010,and is entitled ANKLE INTRAMEDULLARY ARTHRODESIS AND ARTHOPLASTY SYSTEM;

U.S. Provisional Patent Application No. 61/323,170, filed Apr. 12, 2010,and is entitled FUSION METHODS AND DEFORMITY CORRECTION SYSTEM; and

U.S. Provisional Patent Application No. 61/356,948, filed Jun. 21, 2010,and is entitled ANKLE SPACER AND FIXATION.

The above-identified documents are incorporated herein by reference.

FIELD OF THE INVENTION

This invention relates to surgical implants which provide jointarthrodesis or arthroplasty. Specifically, this invention relates toimplants for ankle arthrodesis or arthroplasty.

BACKGROUND OF THE INVENTION

Ankle arthritis is common following a traumatic injury such as an anklefracture, ligament injury or failed open reduction internal fixation.Arthritis is also seen in patients with rheumatoid arthritis and indiabetic patients with charcot arthropathy. In comparison to mostpatients affected by hip and knee arthritis, ankle arthritis patientsare usually younger and have often had prior ankle surgery. Thetreatment goal is to provide pain relief. Currently, patients with anklearthritis are presented with either fusion or arthroplasty as surgicaloptions.

A fusion, or arthrodesis, is an effective solution for pain resultingfrom ankle arthritis and has been the historical gold standard fortreatment. An arthrodesis is currently the recommended option forpatients with diabetic charcot arthropathy, post traumatic patients withpoor bone stock, and in the young active patient with arthritis.Arthrodesis is also a surgical option following failed anklearthroplasty. An ankle arthroplasty is another possible solution forankle arthritis, and often involves a replacement of the distal tibiaand/or a portion of the talus. However, problems exist with some of thecurrent systems for ankle arthrodesis and arthroplasty.

Current systems that perform ankle fusion fixation have certaindisadvantages. First, some cannulated screws have been complicated byhardware failure prior to complete fusion, as well as lack of adequatecompression across the fusion site. Depending on the orientation ofscrew insertion, the screws may not restrict motion in the plane ofmotion of the joint and therefore increase the likelihood of developmentof nonunion. Second, some plate systems are often able to accommodatedeformity in only one plane, and also can cause prominence that leads topostoperative skin irritation. Third, some hindfoot fusion nails havebeen inserted retrograde to treat ankle arthritis. Insertion of theretrograde nail will sacrifice the subtalar joint even though the jointmay not be affected by arthritis. Current retrograde fusion nails arenot designed to specifically fuse the posterior facet of the subtalarjoint. A common complication of current retrograde systems involves anonunion of the posterior facet joint because they do not specificallyfuse this area with the fusion nail. The plantar skin incision that isrequired for the retrograde nail has been associated with woundcomplications and injury to the plantar branch of the tibial nerve. Manyof these forms of ankle arthrodesis require an 8 to 12 week period ofstrict non weight bearing to ensure fusion, and patient compliance withnon weight bearing is often difficult to achieve.

The current generation of ankle arthroplasty systems presentsdisadvantages resulting in poor patient outcomes. Current anklearthroplasty may not be a viable option for patients who have poor bonestock. These patients include those who have undergone past operativeprocedures for fractures and diabetic patients with charcot arthropathy.Poor bone stock in the distal tibia and talus can result in implantmalposition and failure. Second, traditional ankle arthroplasty may notbe an ideal option for the young and active patient because of the riskof increased wear and early implant failure. Third, many current totalankle arthroplasty systems require resection of a significant amount ofbone from both the tibia and talus in order to create a space forinsertion of the implants. These large bone cuts can create a large voidto fill if the ankle replacement fails. A fusion following anarthroplasty with large bone cuts is often complicated by an increasedrate of nonunion.

Therefore, the need exists for improved ankle arthrodesis andarthroplasty systems. An arthrodesis system which provides improvedcompression across the fusion site and/or structural bone support mayresult in improved long-term fusion and pain relief. An arthrodesis orarthroplasty system which relies on anchoring or fixation on strongouter cortical bone instead of compromised bone stock may provide anincreased rate of union, or longer lasting wear, respectively. Anarthroplasty system which requires minimal resection may result inenhanced comfort and mobility. An arthroplasty convertible to a fusionsystem with minimal disturbance of surrounding tissues may result inbetter union following the fusion.

BRIEF DESCRIPTION OF THE DRAWINGS

Various embodiments of the present invention will now be discussed withreference to the appended drawings. It is appreciated that thesedrawings depict only typical embodiments of the invention and aretherefore not to be considered limiting of its scope.

In FIGS. 2, 9, 14, 15, 16, 17, 19, 23, 24, 30, 31, 33, 35, 36 and 37bone portions surrounding implanted objects are rendered as transparentin order to better view the objects and their positioning within thebone portions.

FIG. 1 is an antero-lateral view of a left foot, ankle and lower legskeleton;

FIG. 2 is an antero-lateral view of a partial foot, ankle and lower legwith two compression bolt systems implanted across the tibiotalar joint;

FIG. 3A illustrates the assembled compression bolt system of FIG. 2, thesystem including a nut, a standoff, and a compression bolt; FIG. 3B isan exploded view of the compression bolt system of FIG. 3A; and FIG. 3Cis a transverse cross-sectional view of the nut of FIG. 3A;

FIG. 4A illustrates a compression bolt system with a T-shaped nutconnection; and FIG. 4B is an exploded view of the system of FIG. 4A,the system including a nut, a standoff, a compression bolt, and acortical washer;

FIG. 5A is a front view of the cortical washer of FIG. 4B; FIG. 5B is aside view of the cortical washer of FIG. 4B; and FIG. 5C is across-sectional view of the cortical washer of FIG. 4B, taken along lineC-C in FIG. 5A;

FIG. 6 is an exploded view of a compression bolt system including ananchor including two rotatable tabs, a standoff, a set screw, and acompression bolt;

FIG. 7 illustrates the standoff and tabs of FIG. 6, the tabs in aninsertion configuration;

FIG. 8 illustrates the standoff, set screw and tabs of FIG. 6, the tabsin a deployed configuration;

FIG. 9 illustrates the compression bolt system of FIG. 6 implantedacross a tibiotalar joint in a bone bore extending obliquely through adistal tibia and talus, the anchor disposed in the sinus tarsi inferiorto the talus;

FIG. 10A is an isometric view of a compression bolt system including asingle rotatable tab anchor, the anchor in an insertion configuration;and FIG. 10B is an isometric view of the compression bolt system of FIG.10A with the anchor in a deployed configuration;

FIG. 11A is an isometric view of a standoff, set screw and pairedL-shaped tabs of a compression bolt system, with the paired tabs in aninsertion configuration; FIG. 11B is a bottom view of the paired tabsand standoff of FIG. 11A in the insertion configuration, and acompression bolt; FIG. 11C is an isometric view of the system of FIG.11A with the set screw and paired tabs in a deployed configuration; FIG.11D is a bottom view of the compression bolt, paired tabs and standoffof FIG. 11C in the deployed configuration;

FIG. 12 is an isometric view of a modular targeting guide systemincluding a top arm, upright, targeting guide arm and guide sleeve;

FIG. 13A illustrates an anchor positioning arm attachable to thetargeting guide system of FIG. 12; FIG. 13B illustrates a reamer andFIG. 13C illustrates a driver;

FIG. 14 illustrates the targeting guide system of FIG. 12 guiding aguide wire along a first trajectory through a tibia and a talus;

FIG. 15 illustrates the targeting guide system of FIG. 12 with thedriver of FIG. 13C driving a standoff of a first compression bolt systeminto engagement with a nut held on the anchor positioning arm of theguide system, along the preferred trajectory of FIG. 14;

FIG. 16 illustrates the fully implanted first compression bolt systemimplanted along the first trajectory of FIG. 14, and the targetingsystem of FIG. 12 repositioned along a second trajectory through thetibia and talus, with the driver driving a standoff of a secondcompression bolt system into engagement with a nut held on the anchorpositioning arm of the guide system;

FIG. 17 is a medial view of a tibia, talus and calcaneus illustrating acompression bolt system implanted across the tibiotalar joint andanchored in the sinus tarsi, with a supplementary stabilizing screwimplanted across the joint;

FIG. 18A is a superior and a front view of an anatomic spacing membershaped to fit on the superior side of a talus; FIG. 18B is a superiorand a front view of a flat spacing member; FIG. 18C is a superior and afront view of a wedge-shaped spacing member; and FIG. 18D is a superiorand a front view of an toothed spacing member having bone-engagingridges;

FIG. 19 is a medial view of a tibia, talus and calcaneus with animplanted bone support implant system, the system including the toothedspacing member of FIG. 18D implanted between the talus and the tibia,and a compression bolt system implanted across the tibiotalar joint andanchored in the sinus tarsi;

FIG. 20A is an isometric view of an anatomic spacing member including afixation aperture extending through a spacer body; and FIG. 20B is anisometric view of an anatomic spacing member including a plurality offixation apertures extending through a spacer body;

FIG. 21A is an isometric view of a spacing member including lateralfixation flanges; FIG. 21B is a lateral view of the spacing member ofFIG. 21A; FIG. 21C is an isometric view of a spacing member includinglateral fixation flanges and an anterior fixation flange; FIG. 21D is anisometric view of a plate member;

FIG. 22A is an isometric exploded view of a spacing member including ananterior fixation flange, a supplementary plate and a plurality offixation members; FIG. 22B is an isometric view of the assembled spacingmember, supplementary plate and fixation members;

FIG. 23 is an anterior view of the spacing member of FIG. 20A implantedbetween a talus and a tibia, with a compression bolt system implanted toextend from an exterior surface of the tibia, through a fixationaperture in the spacing member, to the exterior surface of the talus inthe sinus tarsi;

FIG. 24 is a lateral view of a the spacing member of FIG. 22A implantedbetween a talus and a tibia, the fibula not shown for clarity, with acompression bolt system implanted across the tibiotalar joint andthrough a window of the spacing member, and a supplementarystabilization screw implanted along a different trajectory than thecompression bolt system;

FIG. 25 is an isometric view of an ankle arthroplasty system including atibial plate, a bearing insert, a talar plate, and tibial and talaranchors;

FIG. 26 is an exploded view of the ankle arthroplasty system of FIG. 25;

FIG. 27 is a cross-sectional view of the ankle arthroplasty system ofFIG. 25;

FIG. 28A is a superior view of the tibial plate of the anklearthroplasty system of FIG. 25; FIG. 28B is an inferior view of thetibial plate; FIG. 28C is a superior view of the bearing insert of theankle arthroplasty system of FIG. 25; FIG. 28D is an inferior view ofthe bearing insert; FIG. 28E is a superior view of the talar plate ofthe ankle arthroplasty system of FIG. 25; and FIG. 28F is an inferiorview of the talar plate;

FIG. 29A is an isometric view of a modular targeting guide system forimplantation of the arthroplasty system of FIG. 25, including a talarguide, an upright, a guide arm, a guide sleeve, a sinus tarsi guide, anda cutting guide; FIG. 29B is an exploded view of the targeting guidesystem of FIG. 29A;

FIG. 30 is an anterior view of the targeting guide system of FIG. 29Apositioned to guide a guidewire through a tibia and talus along aselected trajectory to a guide arm disposed in the sinus tarsi;

FIG. 31 is an antero-lateral view of a tibia, talus, and calcaneus,illustrating a resected tibial space and a prepared bone bore extendingthrough the tibia and the talus;

FIG. 32A is an isometric view of an ankle arthroplasty trial; and FIG.32B is an isometric view of a tamp;

FIG. 33 is an antero-lateral view of a tibia, talus, and calcaneus withthe ankle arthroplasty system of FIG. 25 implanted in the resectedtibial space and prepared bone bore;

FIG. 34A is an isometric view of a fusion conversion spacing member;FIG. 34B is an anterior view of the spacing member of FIG. 34A; FIG. 34Cis a posterior view of the spacing member of FIG. 34A; FIG. 34D is amedial view of the spacing member of FIG. 34A; FIG. 34E is a lateralview of the spacing member of FIG. 34A, and FIG. 34F is a lateral viewof the tibial plate, bearing insert, and talar plate of the anklearthroplasty system of FIG. 25;

FIG. 35 is an antero-lateral view of a tibia, talus, and calcaneus, withan anchor implanted in the talus, showing a method for implantation ofthe spacing member of FIG. 34A and implantation of a compression boltsystem across the tibiotalar joint;

FIG. 36 is an anterior view of the tibia and talus of FIG. 35 with theimplanted spacing member and compression bolt system, and a plurality ofsupplementary fasteners implanted to provide additional cross-fixationof the system in the tibia and the talus; and

FIG. 37 is a posterior view of a tibia, talus, and calcaneus with a bonefixation system comprising an intramedullary nail and an anchorimplanted across the tibiotalar joint.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

The present invention relates to implants for ankle arthrodesis and/orarthroplasty. Those of skill in the art will recognize that thefollowing description is merely illustrative of the principles of theinvention, which may be applied in various ways to provide manydifferent alternative embodiments. This description is made for thepurpose of illustrating the general principles of this invention and isnot meant to limit the inventive concepts in the appended claims.

One embodiment of the invention may be an implantable bone fixationsystem for providing compression between a first exterior bone surfaceand a second exterior bone surface. The bone fixation system may includea first elongated structure, a second elongated structure, and ananchor. The first elongated structure may have a head and a shaft, thehead shaped to bear against the first exterior bone surface. The secondelongated structure may have a proximal end, a distal end, alongitudinal axis extending between the proximal end and the distal end,and an external diameter perpendicular to the longitudinal axis. Theanchor may be disposed at the distal end of the second elongatedstructure, and have a deployed configuration in which a portion of theanchor protrudes beyond the external diameter of the second elongatedstructure. The anchor may be shaped to bear against the second exteriorbone surface. The shaft of the first elongated structure may becoaxially received by the proximal end of the second elongated structureand may be selectively adjustable relative to the second elongatedstructure to increase or decrease a distance between the head and theanchor to provide a selected level of compression between the firstexterior bone surface and the second exterior bone surface. The bonefixation system may further have an insertion configuration, the anchorselectively movable relative to the second elongated structure betweenthe insertion configuration and the deployed configuration.

The anchor may include a toggle attached to the distal end of the secondelongated structure, the toggle selectively deployable between aninsertion configuration and the deployed configuration. In the deployedconfiguration the toggle is freely pivotable relative to distal end ofthe second elongated structure.

The anchor may include a plurality of tabs attached to the distal end ofthe second elongated structure, the tabs selectively deployable betweenan insertion configuration and the deployed configuration. In thedeployed configuration a portion of each tab protrudes beyond theexternal diameter of the second elongated structure.

The anchor may have a vertical axis and a transverse axis perpendicularto the vertical axis. The anchor may further include a convex bearingsurface shaped to bear congruently against the second exterior bonesurface; and a connection feature shaped to receive a portion of thesecond elongated structure to attach the anchor to the second elongatedstructure, the connection feature obliquely oriented relative to atleast one of the vertical axis and the transverse axis.

The first elongated structure may include an externally threaded boltand the second elongated structure may include a standoff having athreaded bore. The bolt is receivable in the standoff bore and isthreadably adjustable relative to the standoff bore to provide theselected level of compression between the first exterior bone surfaceand the second exterior bone surface.

The head of the first elongated member may include a cortical washer,the cortical washer having a rim shaped to bear congruently against thefirst exterior bone surface and a bore shaped to retain the shaft of thefirst elongated member.

The system may further include a spacing member having a peripheral bodywall and a bore extending therethrough, the spacing member shaped to beinserted between a first bone and a second bone to provide load-bearingsupport between the first bone and the second bone.

A method of implanting a bone fixation system may include inserting afirst elongated structure into an opening in a first exterior bonesurface on a first bone, the first elongated structure comprising a headand a shaft; inserting a second elongated structure into the opening,the second elongated structure having a proximal end, and a distal end,and having a longitudinal axis extending between the proximal end andthe distal end, and an external diameter perpendicular to thelongitudinal axis. The method may include coaxially receiving the firstelongated structure with the second elongated structure, moving ananchor positioned at the distal end of the second elongated structureinto a deployed configuration in which a portion of the anchor protrudesbeyond the external diameter of the second elongated structure, andadjusting the first elongated structure relative to the second elongatedstructure to change a distance between the head and the anchor toprovide a selected level of compression between the first exterior bonesurface and the second exterior bone surface.

The method may include moving the first elongated structure along thelongitudinal axis to adjust the first elongated structure relative tothe second elongated structure. The first elongated structure mayinclude an externally threaded bolt and the second elongated structuremay include an internally threaded standoff. The method may furtherinclude rotating the bolt within the standoff to adjust the firstelongated structure relative to the second elongated structure. Themethod may further include engaging a set screw with the secondelongated structure to urge the anchor into the deployed configuration.The anchor may have a vertical axis and a transverse axis perpendicularto the vertical axis, so that moving the anchor into the deployedconfiguration includes moving the anchor into an orientation in whichthe transverse axis of the anchor is at an oblique angle relative to thelongitudinal axis of the second elongated structure.

The method may include inserting a cortical washer into the opening inthe first exterior bone surface such that a rim of the cortical washerbears congruently against the first exterior bone surface, inserting thefirst elongated structure into the bore of the cortical washer; andretaining the head of the first elongated structure with the bore of thecortical washer.

The method may include inserting a spacing member having a peripheralbody wall and a bore extending therethrough into a space between thefirst bone and the second bone to provide load-bearing support betweenthe first bone and the second bone.

The method may include positioning a mobility structure between thefirst elongated structure and the anchor to allow relative motionbetween the first bone and the second bone.

The method may include creating a straight elongated bore extending fromthe opening in the first exterior bone surface to the second exteriorbone surface along a trajectory oblique to the intramedullary canal ofthe first bone, inserting the first elongated structure along thetrajectory, and inserting the second elongated structure along thetrajectory.

Another embodiment of the invention may be a bone anchor systemimplantable to extend between a first exterior bone surface and a secondexterior bone surface, the bone anchor system including an elongatedstructure having a first end and a second end, the elongated structureinsertable through bone such that the first end is disposed at the firstexterior bone surface and the second end is disposed at the secondexterior bone surface, and an anchor member removably attachable to thesecond end of the elongated structure, the anchor having a vertical axisand a transverse axis perpendicular to the vertical axis. The anchormember may include a curved bearing surface shaped to bear congruentlyagainst the second exterior bone surface, a connection feature obliquelyoriented relative to at least one of the vertical axis and thetransverse axis, and a base surface disposed opposite the convex bearingsurface, the base surface shaped to avoid destructive contact withneighboring bone structures when the anchor member is attached to theelongated structure and the convex bearing surface bears against thesecond exterior bone surface.

The elongated structure second end may include an externally threadedhub and the connection feature may include a threaded bore, the threadedhub is engageable in the threaded bore to attach the anchor member tothe elongated structure.

The elongated structure may have a longitudinal axis extending from thefirst end to the second end, and an external diameter perpendicular tothe longitudinal axis, so that when the anchor member is attached to thesecond end of the elongated structure the transverse axis of the anchormember is at an oblique angle relative to the longitudinal axis of theelongated structure. The curved bearing surface may extend radiallybeyond the external diameter of the elongated structure when the anchormember is attached to the second end of the elongated structure. Thecurved bearing surface may be convex, and the curved bearing surface maybe convexly curved about the transverse axis of the anchor member, theconvex curve having a constant radius along the length of the transverseaxis.

The elongated structure may include a bolt and a standoff, the boltcoaxially received by the standoff and selectively adjustable relativeto standoff to increase or decrease a distance between the first end ofthe elongated structure and the anchor to provide a selected level ofcompression between the first exterior bone surface and the secondexterior bone surface.

The bone anchor system may further include a cortical washer having arim shaped to bear congruently against the first exterior bone surface,and a bore configured to retain the first end of the elongatedstructure.

The anchor member may be sized and shaped to be inserted into a sinustarsi between a talus and a calcaneus, the curved bearing surface shapedto bear congruently against the inferior surface of the talus within thesinus tarsi.

Another embodiment of the invention may be a bone support implant systemincluding a first bone anchoring device and a spacing member. The firstbone anchoring device may have a first end attachable to a firstexterior bone surface on the first bone and a second end attachable to asecond exterior bone surface on the second bone. The spacing member mayhave a peripheral body wall and a bore extending therethrough and beshaped to be inserted between the first bone and the second bone toprovide load-bearing support between the first bone and the second bone.The first bone anchoring device may be configured to extend through thefirst bone, through the spacing member bore, and through the second boneto provide compression between the first exterior bone surface and thesecond exterior bone surface.

The bone support implant system may further include a second boneanchoring device. The second bone anchoring device may be configured toextend through the first bone, through the spacing member bore, andthrough the second bone along a trajectory non-parallel to the firstbone anchoring device to provide additional compression between thefirst exterior bone surface and the second exterior bone surface.

The first bone anchoring device may include a first elongated structureand a second elongated structure. The first elongated structure may becoaxially received by the second elongated structure and selectivelyadjustable relative to the second elongated structure to increase ordecrease a distance between first end and the second end to provide aselected level of compression between the first exterior bone surfaceand the second exterior bone surface.

The spacing member may include a first bone contacting surface and asecond bone contacting surface. At least one of the first and secondbone contacting surfaces may include a plurality of bone engagementfeatures projecting from the bone contacting surface. The spacing membermay be configured to fit into a gap between the first bone and thesecond bone, the gap bounded by a first face of the first bone and asecond face of the second bone. The spacing member may be contoured toconform to the first face of the first bone and the second face of thesecond bone.

The spacing member peripheral body wall may include a medial portion anda lateral portion. A height of the medial portion may be unequal to aheight of the lateral portion to provide a deformity correction when thespacing member is inserted between the first bone and the second bone.The spacing member may be shaped to be inserted into a tibial osteotomybetween a tibia and a talus.

The spacing member may further include a flange protruding from aportion of the peripheral body wall. The bone support implant system mayfurther include at least one fastener configured to fasten the flange toone of the first bone and second bones.

The bone support implant system may further include a cortical washerhaving a rim shaped to bear congruently against the first exterior bonesurface and a bore configured to retain the first end of the first boneanchoring device.

The second end of the first bone anchoring device may further include ananchor member. The anchor member may be movable between an insertionconfiguration and a deployed configuration. In the deployedconfiguration the anchor member may be configured to bear against thesecond exterior bone surface on the second bone.

A method of implanting a bone support implant system for providingstabilizing support between a first bone and a second bone may includeinserting a spacing member into a space between the first bone and thesecond bone, the spacing member comprising a peripheral body wall and abore extending therethrough. The method may further include inserting afirst bone anchoring device to extend through the first bone, throughthe spacing member bore, and through the second bone, attaching a firstend of the first bone anchoring device to a first exterior bone surfaceon the first bone; and attaching a second end of the first boneanchoring device to a second exterior bone surface on the second bone.

Inserting the first bone anchoring device may include inserting thefirst bone anchoring device along a single straight first trajectorythat passes through the first bone, the spacer, and the second bone. Themethod may further include inserting a second bone anchoring device toextend through the first bone, through the spacing member bore, andthrough the second bone, along a single straight second trajectorynon-parallel to the first trajectory.

The method may further include selectively adjusting the length of thefirst bone anchoring device to increase or decrease a distance betweenthe first end and the second end to provide a selected level ofcompression between the first exterior bone surface and the secondexterior bone surface.

The first bone anchoring device may further include a first elongatedstructure and a second elongated structure. The method may furtherinclude coaxially receiving the first elongated structure within thesecond elongated structure, and moving the first elongated structurerelative to the second elongated structure to adjust the length of thefirst bone anchoring device.

The method may further include preparing a tibial osteotomy on thedistal end of a tibia and inserting the spacing member into the tibialosteotomy between the tibia and the talus.

The method may further include inserting a cortical washer into anopening in the first bone such that a rim of the cortical washer bearsagainst the first exterior bone surface on the first bone, and retainingthe first end of the first bone anchoring device with the corticalwasher.

The method may further include moving an anchor member attached to thesecond end of the first bone anchoring device to a deployedconfiguration in which the anchor member bears against the secondexterior bone surface on the second bone.

The method may further include fastening a flange which protrudes from aportion of the peripheral body wall to at least one of the first andsecond bones.

Yet another embodiment of the invention may include a modular orthopedicarthroplasty system for controlling relative motion between a first boneand a second bone. The modular orthopedic arthroplasty system mayinclude first and second anchor members, first and second elongatedstructures, and a mobility structure. The first anchor member may beshaped to bear against a first exterior bone surface on the first bone.The second anchor member may be shaped to bear against a second exteriorbone surface on the second bone. The first elongated structure may havea first end and a second end, the first end attachable to the firstanchor member. The second elongated structure may have a first end and asecond end, the second end attachable to the second anchor member. Themobility structure may be positioned between the first elongatedstructure and the second elongated structure to allow relative motionbetween the first bone and the second bone.

The mobility structure may further include a first bearing body, a firstbearing surface, a second bearing body and a second bearing surface. Thefirst bearing body may be removably coupled to the first elongatedstructure and the second bearing body may be removably coupled to thesecond elongated structure. The second bearing surface may be shaped tobear against the first bearing surface to allow articulating relativemotion between the first and second bearing surfaces. The firstelongated structure may include a first bolt and a first sleeve. Thefirst bolt may be coaxially received in the first sleeve, and the firstbolt may be selectively movable relative to the first sleeve to increaseor decrease a distance between the first anchor member and the firstbearing surface. The second elongated structure may include a secondbolt and a second sleeve. The second bolt may be coaxially received inthe second sleeve, and the second bolt may be selectively movablerelative to the second sleeve to increase or decrease a distance betweenthe second anchor member and the second bearing surface. The system mayfurther include a bearing insert shaped to be inserted between the firstbearing body and the second bearing body. The bearing insert may includeone of the first bearing surface and the second bearing surfaces.

The first anchor member may be shaped to bear congruently against theexterior surface of a tibia. The second anchor member may be shaped bearcongruently against the inferior surface of a talus. The mobilitystructure may be shaped to be inserted into a space between the tibiaand the talus.

The second anchor member may have an insertion configuration and adeployed configuration. The second anchor member may be selectivelymovable between the insertion configuration and the deployedconfiguration. In the deployed configuration the second anchor membermay be positioned to bear against the second exterior bone surface.

The modular orthopedic arthroplasty system may further include a thirdelongated structure. The third elongated structure may be configured toextend between the first exterior bone surface and the second anchormember to substantially prevent relative motion between the first boneand the second bone.

The modular orthopedic arthroplasty system may further include a spacingmember having a peripheral body wall and a bore extending therethrough.The spacing member may be shaped to be inserted between the first boneand the second bone to provide load-bearing support between the firstbone and the second bone.

A method for implanting a modular orthopedic arthroplasty system mayinclude extending a first elongated structure through a first bone, thefirst elongated structure having a first end and a second end, the firstend attached to a first anchor member. The method may further includepositioning the first anchor member to bear against a first exteriorbone surface on the first bone and retain the first elongated structurein the first bone. The method may further include extending a secondelongated structure through a second bone, the second elongatedstructure having a first end and a second end, the second end attachedto a second anchor member. The method may further include positioningthe second anchor member to bear against a second exterior bone surfaceon the second bone. The method may further include positioning amobility structure between the first elongated structure and the secondelongated structure, the mobility structure allowing relative motionbetween the first bone and the second bone. The method may furtherinclude attaching the mobility structure to the first elongatedstructure and the second elongated structure.

The mobility structure may further include a first bearing body, a firstbearing surface, a second bearing body, and a second bearing surface.The method may further include removably coupling the first bearing bodyto the first elongated structure and removably coupling the secondbearing body to the second elongated structure.

The method may further include adjusting a length of the first elongatedstructure to increase or decrease a distance between the first anchormember and the first bearing surface. The method may further includeadjusting a length of the second elongated structure to increase ordecrease a distance between the second anchor member and the secondbearing surface.

The elongated structure may include a first bolt received coaxially in afirst sleeve. The method may further include adjusting the length of thefirst elongated structure by moving the first bolt relative to the firstsleeve.

The method may further include inserting a bearing insert between thefirst bearing body and the second bearing body. The bearing insert mayinclude one of the first bearing surface and the second bearing surface.

The method may further include placing the first bone and the secondbone in a preferred orientation relative to one another and creating astraight elongated bore extending through the first bone and the secondbone along a single trajectory oblique to the intramedullary canal ofthe first bone. Extending the first elongated structure through thefirst bone may include inserting the first elongated structure into thestraight elongated bore. Extending the second elongated structurethrough the second bone may include inserting the second elongatedstructure into the straight elongated bore. Extending the firstelongated structure through the first bone may include extending thefirst elongated structure through a tibia. Extending the secondelongated structure through the second bone may include extending thesecond elongated structure through a talus. Positioning the mobilitystructure between the first elongated structure and the second elongatedstructure may include inserting the mobility structure into a spacebetween the tibia and the talus.

The method may further include removing the mobility structure frombetween the first elongated structure and the second elongatedstructure, extending a third elongated structure through the first boneand the second bone, and attaching the third elongate structure to thesecond elongated structure to substantially prevent relative motionbetween the first bone and the second bone.

The method may further include inserting a spacing member between thefirst bone and the second bone, and extending the third elongatedstructure through the first bone, through the spacing member, andthrough the second bone.

FIG. 1 illustrates an antero-lateral view of the skeleton of a leftfoot, ankle and distal leg portion. The distal leg portion includestibia 2 and fibula 4. The bones of the ankle and foot include: talus 6,calcaneus 8, navicular 10, cuboid 12, cuneiforms 14, metatarsals 16, andphalanges 18. The sinus tarsi 20 is a canal-like space formed betweenthe inferior surface of the talus at the sulcus tali and the superiorsurface of the calcaneus at the calcaneal sulcus.

In at least one embodiment, the present invention provides an anklearthrodesis system which provides compression across the tibio-talarjoint to promote improved bone fusion and joint stability. Referring toFIG. 2, two individual compression systems 100 are shown implantedacross a tibio-talar joint, each extending along an oblique trajectoryfrom the an outer surface of the tibia, through the talus, andterminating in the sinus tarsi. A portion of the fibula 4 is not shownin order to better view the implanted systems. Each compression system100 includes standoff 102, compression bolt 104, and compression nut106. The compression system 100 and alternative embodiments disclosedherein may be referred to as a compression bolt system, a bone anchoringsystem or device, or a bone fixation device.

FIG. 2 illustrates an embodiment of a bone fixation system in which twobone anchor systems 100 a, 100 b are implanted across the sametibiotalar joint. Bone anchor system 100 a is installed in a preparedbone bore which extends along a single trajectory between an outersurface of the tibia and an outer surface of the talus, in the sinustarsi. A portion of the fibula is not shown in order to view theimplants more clearly. The addition of a second bone anchor system 100b, implanted in a second prepared bone bore along a single trajectory atan angle oblique to the first system, provides additional stability,compression and fixation across the joint. Implanting two systems atoblique angles may provide cross-fixation to prevent any potentialrotation, leading to loosening, about the axis of a single system.

FIGS. 3A and 3B display compression system 100 in an assembled and anexploded configuration. Standoff 102 is an elongated structure having afirst end 108, a second end 110, and a body 112 extending therebetween.At the first end, a driver engagement feature 109 is shaped to engage adriver or other instrument used in implanting and the standoff. Astandoff tip 114 projects from the second end 110. Depending on theimplanted orientation of the system, the first end 108 may be a proximalend and the second end 110 may be a distal end. The standoff 102 is atleast partially cannulated, having a lumen 116 extending from an openingat the first end 108 along some or all of the length of the standoff.The standoff 102 is internally threaded, with internal threads 118extending the length of the standoff or at least a portion adjacent thefirst end 108. The standoff tip 114, which may also be called a hub,includes external threads 120. A plurality of openings 121 may belocated along the standoff body 112, and may be aligned in pairs suchthat two openings 121 are positioned opposite one another along thestandoff body 112, either directly across from one another or at anoblique angle. The openings 121 may allow bony ingrowth into thestandoff once implanted, and may also receive additional bolts or screwsfor further stabilization of the device. Other embodiments of thestandoff may lack openings 121.

Compression bolt 104 is an elongated structure including a first end 122which may be a proximal end, a second end 124 which may be a distal end,and a bolt body 126 extending therebetween. The bolt body 126 furtherincludes a head 128 at the first end 122, and a threaded shaft 130. Thethreaded shaft 130 is sized to be received in the standoff lumen 116,and the threaded shaft 130 is threadably engageable with the standoffinternal threads 118. The head 128 may include a driving feature 132which is shaped to connect with a driver and may be formed as a hexagon,star, square, triangle, or rectangle, among others. A bearing surface134 is formed on the head, and in at least one embodiment is formed onthe underside of the head adjacent to where it joins to the shaft. Whenthe system 100 is implanted across a tibio-talar joint and compressionbolt 104 tightened, bearing surface 134 bears against the strongcortical bone of the tibia and compression is provided between the head128 and the compression nut 106, which is anchored against the inferiortalar surface in the sinus tarsi.

Compression nut 106, which may also be called an anchor member, is seenin cross-section in FIG. 3C and includes a nut body 138 having avertical axis 139 and a transverse axis 141. A threaded opening 140extends partially or entirely through the nut body. Threaded opening 140is a connection feature sized to receive the threaded standoff tip 114,and may be positioned perpendicular or oblique to the transverse axis141 of the nut body. When attached to the standoff, the transverse axisof the nut may be at an oblique angle relative to the longitudinal axisof the standoff, as seen in FIG. 3A. Oblique positioning of the threadedopening 140 may allow the compression nut to better conform to theirregular shape of the talus, thence providing a firm seating for thenut against the talus. The compression nut 106 further includes abearing surface 142 which bears against the talus when the bolt 102 istightened and the system 100 is compressed. Bearing surface 142 may berounded, or may be flattened, or any other shape which provides desiredsurface contact with the talus or other bone. For example, as seen inFIGS. 3A-3C, bearing surface 142 may be convexly curved in the form of apartial cylinder to bear congruently against the bone surface, such asthe inferior side of the talus in the sinus tarsi. In some embodimentsincluding obliquely threaded embodiments, a recess 144 is locatedadjacent the threaded opening 140 to provide space for the second end110 of the standoff when the standoff is tightened or locked onto thenut. On the obverse side of the nut from the bearing surface 142 is abase surface 146, which is shaped to avoid destructive contact withneighboring bone structures such as the calcaneus. Base surface 146 maybe flat as in FIG. 3C, or concavely or convexly curved as desired to fitinto the anatomical environment. In some embodiments, a second opening148 is a guide connection feature, providing a means for connection to aguidance instrument. Second opening 148 may be threaded or includerecesses or other shaping which connects with a guide arm or otherguidance instrument. In alternative embodiments of the invention, thestandoff may include the threaded opening, or female connector, whilethe nut may include the projecting tip, or male connector.

In use, the standoff 102 is threadably connected to the compression nut106 to form an anchor at the second end of the standoff. The bolt 104 isthreaded into the first end of the standoff and selectively tightened toincrease or decrease the distance between the head and the nut toprovide a selected level of compression between the bolt head and thecompression nut, or anchor. This construct may provide an advantage overa simple nut and bolt configuration because inclusion of the standoffallows for the variability in length necessary to achieve thecompression. In addition, the variable length allows the device to fitin a wide range of patient anatomies.

Referring to FIGS. 4A and 4B, an alternative embodiment of thecompression system is shown an assembled and exploded views. Compressionsystem 160 includes standoff 162, compression bolt 164, compression nut166, and cortical washer 168. Standoff 162 may share many of thefeatures of standoff 102, with at least the exception of standoff tip170, which is shaped as a T. Compression nut 166 is formed similarly tocompression nut 106, except that nut 166 includes keyway 172, which isshaped to receive standoff tip 170. Standoff 162 lockably connects tocompression nut 166 by inserting standoff tip 170 into keyway 172, andturning the standoff 162 one-quarter turn relative to the compressionnut 166. It is appreciated that alternative embodiments of the systemmay include standoff-nut connections that require more or less thanone-quarter turn to lock together. It is further appreciated that otherstandoff-nut connections are contemplated within the scope of theinvention, including but not limited to threaded connections, snap fitconnections, quarter-turn connections, and other keyed connections.

In any of the embodiments disclosed herein, a cortical washer 168 may beincluded as part of the compression system. Referring to FIG. 5,cortical washer 168 is generally funnel-like or graduated, having afirst exterior opening 210 which is greater in diameter than a secondinterior opening 212. A washer body 214 including a washer bore 216extends between the two openings, the bore constricted by an internalshoulder 218. The shoulder 218 is sized to retain the head of acompression bolt such as compression bolt 164. The first exterioropening 210 is encircled by a rim 220 which projects laterally from theopening. The inferior surface of the rim 220 includes a rim bearingsurface 222, which may be compressed against a bone surface during use.The first exterior opening 210 and surrounding rim 220 may be ellipticalas in FIG. 4a , or in other embodiments may be circular, oval, square,hexagonal, rectangular or another shape. The rim bearing surface 222 maybe curved or otherwise shaped to fit congruently against the corticalbone surface to which it is fixed. Additionally, the first exterioropening 210 and rim 220 may be positioned oblique relative to the washerbore 216 as in the illustrated embodiment, or perpendicular in alternateembodiments. In this and other embodiments, the exterior of washer 168may include threads, fins, porous coatings, surface treatments,apertures or other bone-engaging features to assist in engagement withthe surrounding bone.

Cortical washer 168 may be placed in the opening on the tibial surfacesuch that its rim sits on the cortical shell of the tibia, and thecompression bolt is inserted into the washer, wherein the washer retainsthe bolt head. Or, alternatively, the compression bolt may be firstinserted into the washer followed by placement of the washer into theopening as the bolt is inserted into the standoff. The rim of the washerdistributes the compressive load of the bolt head across a greatersurface area of the tibial surface than would the bolt head alone. Insome instances, the washer also may provide a lower profile between thetibia and the surrounding tissues than would the bolt head alone, as thebolt head is recessed in the washer and only the flat rim of the washerprotrudes above the surface of the tibia.

Another alternative embodiment of a compression system is shown in FIGS.6-11, which depict bolt and standoff combinations including toggle-typeanchors at one end. Referring specifically to FIGS. 6-9, compressionsystem 180 is shown in an exploded view, in a retracted or insertionconfiguration, a deployed configuration, and implanted across atibotalar joint in a compressed configuration. Compression system 180includes standoff 182, compression bolt 184, toggle mechanism 186, andset screw 188. Standoff 182 includes a first end 190, a second end 192,and a threaded bore 194 extending therebetween. A pair of standoffextensions 196 projects longitudinally from the second end 192, and apin 198 extends between the standoff extensions to form a pivot pointfor the toggle 186. Toggle 186 includes first and second tabs 200, 202which are pivotable about the pin 198. In the insertion configurationseen in FIG. 7, the tabs are pivoted so that both point toward the firstend 190 of the standoff. The tabs 200, 202 are sized and shaped so thatwhen in the insertion configuration, they do not protrude farther thanthe diameter of the standoff, allowing for smooth unimpeded insertion ofthe standoff through the tibia; in this configuration the tabs cannotcatch or snag on the tibia during insertion. Shaping features of thetabs may include beveling or rounding of the tab ends.

The set screw 188 is sized to be received in the threaded bore 194 ofthe standoff, and may be already threaded into the bore 194 as thestandoff is inserted. Once the standoff is properly positioned in thetibia, the set screw 188 may be turned until it emerges distally fromthe second end 192 of the standoff, contacts the tabs 200, 202 andpivots the tabs into the deployed configuration, in which the tabsproject approximately perpendicular relative to the standoff. In thislocked, deployed configuration, the standoff and tabs may form an anchorshape or T shape as seen in FIG. 8. In other embodiments, in thedeployed configuration, the tabs may project at an oblique angle, or maypartially pivot to form a V shape.

Compression is achieved by threading the compression bolt 184 into thestandoff 182 until contact between a bolt head bearing surface 206 bearsagainst the tibia. Continued threading of the compression bolt 184 intothe standoff draws the standoff toward the bolt head, or proximally,until the toggle 186 is seated against the lower surface of the talus ata selected pressure, illustrated in FIG. 9. In this embodiment, each tab200, 202 provides a bearing surface which bear against the talus in thecompressed configuration. As with other embodiments of the compressionsystem, a cortical washer may be inserted between the bolt head and thetibial opening. It is appreciated that in this embodiment of theinvention, the deployment of the toggle and the compression of thesystem are carried out by separate actions. Engagement of the set screwwith the toggle tabs deploys the toggle, while engagement of the bolt inthe standoff provides the compressive force between the bolt head orcortical washer, and the toggle 186.

FIGS. 10A and 10B illustrate an alternative embodiment of a compressionsystem including a single tab or toggle which actuates by flipping orrotating into a deployed position. Compression system 230 includesstandoff 234, compression bolt 232, tab 236, and optional corticalwasher 168. Standoff 234 is internally threaded to receive compressionbolt 232, and further includes a pair of extensions 240 between which agap 242 is formed. Tab 236 is rotatably joined to the extensions 240 bya pin 244. The pin 244 provides a pivot point about which tab 236 mayrotate, and in rotation a portion of the tab 236 is positioned in thegap 242. In an insertion configuration, illustrated in FIG. 10A, tab 236is rotated so that it is aligned longitudinally with the standoff 234.In this position, the standoff may be inserted into the prepared reamedhole in the tibia and talus until the standoff extensions 240 protrudeinto the sinus tarsi. When the standoff is sufficiently inserted so thatthe tab 236 encounters the calcaneus, contact with the calcaneus mayurge rotation of the tab 236 to the deployed position seen in FIG. 10b ,in which the tab is approximately perpendicular to the longitudinal axisof the standoff. Advantageously, depending on the shapes of the sinustarsi and the lower surface of the talus, the tab may assume an obliqueangle relative to the longitudinal axis of the standoff when in thedeployed position. The compression bolt 232 is threadably engaged in thestandoff and turned until a selected level of compression is achievedbetween the bolt head, or cortical washer 168, and the tab 236. Duringand after compression the angle of the tab 236 may shift slightly as thetab 236 seats or bears against the talus.

Referring to FIGS. 11A-11D, another alternate embodiment of acompression system or bone anchoring system is shown. Bone anchoringsystem 250 includes standoff 252, compression bolt 254, a plurality oftabs 256, and set screw 258. The system may further include a corticalwasher 168. Standoff 252 is internally threaded to receive compressionbolt 254 at a first or proximal end 260, and internally threaded toreceive set screw 258 near a second or distal end 262. The tabs 256 arecoupled to the standoff 252 near the distal end 262, and each ispivotable between an insertion configuration, seen in FIGS. 11A and 11B,and a deployed configuration seen in FIGS. 11C and 11D. Although FIGS.11A-1D depict an embodiment with two tabs 256, it is appreciated thatother embodiments may include greater numbers of tabs.

Each of the paired tabs 256 is generally L-shaped, having a first leg264 and a second leg 266. Portions of each leg may include beveledportions 268 which are angled to the major surfaces of the legs. Thesebeveled portions 268 cause the tabs, when in the insertionconfiguration, to have an outer transverse dimension which is less thanor equal to the outer diameter of the standoff, so that the system maybe implanted into a bone bore having a diameter equal to or slightlygreater than the standoff. During implantation into a prepared bone boreacross a joint, the standoff 252 may be inserted into the bone bore inthe insertion configuration with set screw 258 already threaded into thestandoff lumen but not fully impinging on the tabs 256. The standoff 252is inserted until the second legs 266 of the tabs 256 have passedthrough the bone bore and extend past the exterior bone surface. The setscrew 258 is actuated until it impinges on the first legs 264 of thetabs 256, pivoting the tabs from the insertion configuration to thedeployed configuration, and holding the tabs in the deployedconfiguration. The compression bolt 254 is inserted in the distal end ofthe standoff and rotated to decrease the distance between a bolt head270 and the tabs 256. The bolt head 270, or cortical washer 168 if used,will compress against the exterior bone surface at a first end of thebone bore, and the tabs 256, specifically second legs 266, will compressagainst the exterior bone surface at a second end of the bone bore. Thebolt 254 may be selectively tightened to provide a selected level ofcompression across the joint.

It is appreciated that the embodiments illustrated in FIGS. 6-11D may beimplanted solely through a single opening reamed through the tibia andtalus. No additional openings to access the sinus tarsi are required,since in each embodiment the toggle or tabs do not require lateralaccess or contact to be deployed.

Bone fixation systems described herein, including 100, 100 a, 100 b,160, 180, 230, 250 and others may be implanted using a modular targetingguide system 300, as illustrated in FIGS. 12-16. FIG. 12 depicts oneconfiguration of guide system 300, including targeting guide arm 302,upright 304, top arm 306, and guide sleeve 310. Targeting guide arm 302is removably connectable to upright 304, allowing guide arms ofdiffering lengths, sizes and angles to be used depending on patientanatomy and particular trajectory of the implantation of the bonefixation system. Upright 304 is also removably connected to top arm 306.Top arm 306 is generally U-shaped to allow positioning of the top armaround the patient's leg, although it is appreciated the top arm mayinclude other shapes selected to complement other bone structures ordiffering patient sizes. Top arm 306 includes a retaining feature 308which is shaped to hold the generally tubular guide sleeve 310.Targeting guide arm 302 further includes targeting nut 312 having atarget point 318. Targeting nut 312 is sized and shaped similarly to nut106, and may be formed unitarily with the guide arm or may be removable.Guide sleeve 310 is positioned to guide a guide wire along a singleselected trajectory to meet a target point 318 on targeting nut 312. Adistal end 319 of the guide arm may be shaped to orient targeting nut312 at a selected angle, which may be oblique, relative to thelongitudinal axis of guide sleeve 310.

Guide system 300 includes further arms and tools shown in FIGS. 13A-13C,which may be selectively used to perform implant installation actionsdescribed herein. FIG. 13A depicts a nut positioning arm 322 including atargeting nut retainer 314 having a threaded shaft 316. FIG. 13B depictsa reamer 330; FIG. 13C depicts a standoff/bolt driver 324 including adriving feature 326. It is also appreciated that guide system 300 mayinclude features for attachment to a surgical table, framework or otherplatform to provide stability for the framework during surgicalprocedures utilizing the system.

FIG. 14 depicts targeted guide system 300 positioned about the tibia andfibula of a patient's leg with a guide wire 320 distally and laterallyinserted through a portion of the tibia. The distal end 319 of targetingguide arm 302 with targeting nut 312 has been inserted into the sinustarsi, between the talus and the calcaneus. The guide sleeve 310, whichmay also be termed a drill guide, guides the guide wire 320 to passalong the selected trajectory through the tibia and the talus to meetthe target point 318 on the targeting nut 312. Once the guide wire hasbeen inserted through the tibia and talus, guide system 300 may beremoved, leaving the guide wire in place. The reamer 330, which may becannulated to fit over the guidewire, is passed along the selectedtrajectory to ream a bone bore of a preferred diameter through the tibiaand talus along the trajectory. The preferred diameter may be the outerdiameter of the standoff of bone fixation system to be implanted.

After the bore is reamed along the selected trajectory, the nutpositioning arm 322 may be attached to the guide system 300 in place ofthe guide arm 302. Nut positioning arm 322 includes targeting nutretainer 314, which has a threaded shaft 316 which extends through abore in nut positioning arm 322 to removably attach to and retain nut106 at a distal end 324 of the guide arm. The threaded shaft 316threadably engages in second opening 148 of the nut 106. It isappreciated that other means may be used to attach compression nut 106to guide arm 302, such as retaining arms, tongs, threaded connections,and shaped connections, among others. Guide system 300 is positionedadjacent the patient's leg and the distal end of the nut positioning arm322 with attached nut 106 is positioned with the nut 106 in the sinustarsi at the opening to the bone bore.

Referring to FIG. 15, standoff 102 is inserted into the reamed bone boreand connected with the compression nut 106. A standoff driver 324, whichmay be guided through retaining feature 308, rotates the standoff 102relative to the nut 106 so that standoff tip 114 threadably engages inthe threaded opening 140 of the compression nut 106. Thus the nut 106attains a deployed configuration. The nut positioning arm 322 preventsthe nut from rotating during the tightening of the standoff. It isappreciated that for other embodiments of the invention, the standoffmay not need to be rotated to engage with or deploy an anchor. Thestandoff driver 324 includes a driver feature 326 which engages withdriver engagement feature 109 on the standoff to rotate the standoff.The driver feature and driver engagement features may be complementarilyshaped with a hex connection, square connection, star connection orother connection known in the art to allow the driver to actuate thestandoff.

Once the standoff 102 is properly positioned in the bone bore andconnected to the compression nut 106, nut positioning arm 322 and guidesystem 300 may be removed; optionally, it may stay in place and beremoved after engagement of the compression bolt 104 with the standoff102. For removal, threaded shaft 316 of the targeting nut retainer 314is unthreaded from the compression nut, and the nut positioning arm 322is withdrawn. The remainder of the implantation may be performed withoutemploying the guide system 300. Compression bolt 104 is inserted intothe bone bore and threaded into the standoff internal threads 118. Abolt driver is engaged with the driving feature and actuated to move thebolt relative to the standoff. The bolt driver may be the sameinstrument as the standoff driver. As the bolt 104 is tightened, thedistance between the bolt head 128 and nut 106 decreases as the boltmoves along the standoff lumen 116. Bolt 104 may be tightened until head128 contacts the exterior bone surface around the bore entrance on thetibia, at which point further tightening may draw standoff 102 and nut106 toward the head 128, compressing the tibiotalar joint into a fixedrelationship and substantially preventing relative motion between thetibia and the talus across the joint.

Optionally, a second compression system may be implanted, as shown inFIGS. 2 and 16. The guide system 300 may be repositioned with thetargeting nut 312 of the guide arm 102 inserted into the sinus tarsi,the targeting nut 312 adjacent the first implanted compression nut 106.The system 300 is positioned so that guide sleeve 310 will guide theguidewire 320 along a second trajectory which may be non-parallel to thefirst trajectory and first compression system. The remaining steps arecompleted as set forth above to insert the guide wire, ream the bonebore, insert the second nut, insert the second standoff and connect tothe second nut, and tighten the second bolt into the second standoff.

Other embodiments of the compression system, or bone fixation system maybe implanted in a similar manner using some or all the instrumentsdisclosed above. For example, compression system 160 includingquarter-turn nut 166 may be implanted using guide system 300. Nutretaining arm 322 may retain quarter-turn nut 166 in the same manner asit retains nut 106. Compression systems 180, 230 and 250 includingtoggle type anchors may not require use of the nut retaining arm, butthe remainder of the guide system 300 may be implemented to position andimplant the systems.

Another embodiment of the invention includes a first compression systemas set forth herein implanted across a joint to immobilize the joint,plus a screw implanted across the joint along a trajectory differentfrom the trajectory of the first compression system to provide furtherstabilization. This combination might be utilized in an ankle fusionprocedure if it is determined that the sinus tarsi cannot accommodatemore than one anchor member.

Referring to FIG. 17, an alternate embodiment of a compression boltsystem and screw combination is shown. FIG. 17 depicts a medial view ofa tibia, talus, and calcaneus with a compression bolt system 100 and asupplementary screw 340 implanted across the tibiotalar joint. A head342 of screw 340 is positioned at the exterior bone surface of thetibia, and a tip 344 of the screw is lodged within the talus; in thisembodiment the screw does not extend entirely across the talus to emergeoutside of the talus, unlike the anchoring nut 106 of the compressionsystem 100. In another embodiment, the screw 340 may be implanted totraverse the compressing bolt system 100, passing through two of theopenings 121 in the standoff 102. It is appreciated that guide system300 may be implemented to position and implant screw 340 as well ascompression system 100.

Suitable materials for the hardware disclosed herein, including but notlimited to compression bolts, standoffs, screws, washers, toggles, tabs,nuts, and anchors, may include any biocompatible metals and metalalloys, including titanium/titanium alloys, stainless steel, cobaltchrome, tantalum, and barium.

During preparation of a tibiotalar joint for fusion it is oftennecessary to remove significant amounts of cartilage. In this situation,a spacer inserted into the resected area can serve to fill the space,and provide structural load-bearing support and stability to thesurrounding environment. In addition, a spacer may help prevent leglength discrepancy, and can provide deformity correction. Such a spacermay be referred to as a bone support implant.

Referring to FIGS. 18A-C, multiple embodiments of a tibiotalar spacermember, or spacer, are shown. Each spacing member may be implanted intoa resected tibiotalar joint alone, or in combination with any of thecompression bolt systems described herein, the compression bolt systempassing through an opening in the spacer member to anchor the spacermember in a desired position. Spacer members may further includeopenings for screw fixation, and/or anterior or lateral plates foradditional stabilization and screw fixation. The spacer geometry can bevaried to suit the selected surgical technique, or patient anatomy. Forexample, a surgeon may prefer to resect the bone surfaces flat toachieve conformance, in which instance a spacer member with flatinferior and superior surfaces may be optimal. In another example, thespacer may need to be tapered or wedge-shaped to accommodate or correctpatient anatomy.

FIG. 18A illustrates superior and front views of an anatomic spacingmember 400 which is anatomically shaped to congruently fit the superiorside of a talus. Spacing member 400 includes a peripheral wall 402 whichencircles a generally central graft opening or window 404. The spacingmember 400 further includes a superior side 406 and an inferior side408, a first end 410 and a second end 412. Spacing member 400 isgenerally arched or curved, the superior side 406 being convexly curvedbetween the first end and the second end, and the obverse inferior side408 being concavely curved between the first end and the second end. Amedial side 418 is opposite a lateral side 416, and the superior 406 andinferior 408 sides are also slightly curved between the medial side andthe lateral side. Of course, in other embodiments, the spacing membermay be curved in only one aspect and not the other, and/or the superiorside may be concavely curved while the inferior side is convexly curved.

FIG. 18B illustrates a box-like or flat spacing member 420, including aperipheral wall 422 and a window 424. Spacing member 420 is flat, withsuperior and inferior sides spaced evenly apart. However, the perimeterwall 422 and window 424 are irregularly shaped, like those in anatomicspacing member 400, to generally fit the cross-sectional shapes of thetibia and the talus between which it may be implanted.

FIG. 18C illustrates a wedge-shaped deformity correcting spacing member430, having a peripheral wall 432 and window 434. A superior side 436 issloped or angled relative to an inferior side 438. A lateral side 440has a greater height than a medial side 442, as measured from theinferior surface to the superior surface at the respective lateral andmedial sides. In other embodiments, the medial side may be taller thanthe lateral side, or the heights at the first and second ends may differto provide alternate deformity corrections.

Any of the spacing members disclosed herein may include teeth, keels,ridges, splines, porous coatings, surface roughening, or other featuresor treatments on any surface to enhance engagement with surroundingstructures and prevent migration of the spacing member. As seen in FIG.18D, a toothed spacing member 450 is anatomically shaped like spacingmember 400, and further includes a plurality of teeth 452 arrayed onboth the superior and inferior sides. A first section 454 and a secondsection 456 remain toothless, which may aid in implantation of thespacing member and interaction with adjacent anatomy.

FIG. 19 illustrates a medial view of toothed spacing member 450implanted in a tibiotalar joint, with a compression bolt system 230providing additional fixation for the spacing member. Spacing member 450is positioned to congruently fit on the superior surface of the talus,and fill space between the talus and the tibia. Cortical washer 168provides an anchor on the exterior bone surface at a proximal end on thetibia, and tab 236 provides an anchor on the exterior bone surface at adistal end on the talus, in the sinus tarsi. The combination of thespacing member and compression bolt system may be referred to as a bonesupport implant system.

FIGS. 20-22 provide additional spacing member embodiments. FIG. 20Aillustrates spacing member 460, including spacer body 462, peripheralwall 464, window 466, and fixation aperture 468. Fixation aperture 468extends between superior and inferior surfaces of the spacer body 462,and is sized to receive a compression bolt system such as system 100,160, 180, 230 or 250. The aperture may be angled relative to the spacerbody to accommodate the proper trajectory for the compression boltsystem and standoff. An additional compression bolt system, or a screw,may be implanted to pass through the window 466.

FIG. 20B illustrates spacing member 470, including spacer body 472,peripheral wall 474, and window 476. A plurality of fixation apertures478 extend through the spacer body and/or the peripheral wall. Fixationapertures 478 are configured to receive bone screws, bolts, or otherbone anchors. Each individual fixation aperture 478 may have a differenttrajectory, angle, or orientation relative to the spacing member inorder to provide optimal fixation and stability when fixation membersare positioned to extend through the apertures to attach the spacingmember to a bone. Each fixation aperture 478 may be graduated or have atapering diameter through the spacer body or peripheral wall, providinga low profile spacing member system in which the fixation members arerecessed into the fixation aperture and do not protrude beyond theexterior surface of the spacing member. Also, each fixation aperture 478may be threaded to receive a bolt at a preferred trajectory. It isappreciated that a bolt may be driven through a fixation aperture 478from either a generally anterior to posterior direction, or from agenerally posterior to anterior direction. At least one fixationaperture 478 is oriented so that a bolt or screw may be installed froman anterior approach through the aperture without intersecting theadjacent metatarsal, cuneiform and navicular bones.

Referring to FIGS. 21A-C and 22, spacing members including flanges orplates which may provide fixation and/or structural support areillustrated. FIGS. 21A and 21B illustrate an anatomically shaped spacingmember 490 which further includes two fixation flanges disposed on thelateral side of the spacing member. Spacing member 490 includes spacerbody 492, window 496, and support structure 498. A portion of the spacerbody 492 forms a peripheral wall 494 surrounding the window 496. Supportstructure 498 further includes a first flange 500 and a second flange502, each flange projecting outwardly at an angle from the spacer body492. Each flange 500, 502 includes a plurality of fixation apertures 504sized to receive a fixation member such as a bone screw, bolt, or otherbone anchor. The flanges are positioned so that when the spacing body492 is implanted into the space between a tibia and a talus, fixationmembers may be secured into the tibia through the apertures 504 inflange 500, and fixation members may be secured into the talus throughthe apertures 504 in flange 502. It is appreciated that in otherembodiments, the flanges may be positioned on the medial, anterior,and/or posterior sides of the spacer body.

Referring to FIG. 21C, a spacing member 510 includes a spacer body 512,first 514 and second flanges 516 disposed on a lateral side of thespacer body, and a third flange 518 disposed on an anterior aspect ofthe spacer body. A plurality of fixation apertures 520 extend throughthe flanges 514, 516, 518 and the spacer body 512 to allow placement ofmultiple fixation members to secure the spacing member to bonystructures. It is appreciated that due to patient anatomy, compromisedtissues, or surgeon preference, not every fixation aperture must be usedin securing the device to the bony structures; some apertures may beleft empty if desired.

In another embodiment, a plate member alone may be fixed to the tibiaand talus to providing stabilization and/or fusion of the tibiotalarjoint. Depicted in FIG. 21D, plate member 522 comprises a first flange524 and a second flange 526. A plurality of fixation apertures 528provide openings through the flanges, through which fixation members maypass to secure the plate member to bony structures. The fixation membersmay be oriented polyaxially in a variety of planes to providemulti-angle cross-fixation. Alternately, the fixation members may beoriented in coplanar arrangement with one another. The angularrelationship between the first and second flanges 524, 526 may varyaccording to patient size, specific anatomy and/or deformity correctionas necessary. Plate member 522 may be implanted anteriorly or laterallyas needed and can be inserted with minimal exposure.

Referring to FIGS. 22A and 22B, a spacing member 530 includes a spacerbody 532, window 533, flange 534, supplementary plate 536 and aplurality of fixation members 540. Spacer body 532 and flange 534 eachinclude at least one fixation aperture 538, through which fixationmember 540 may pass to secure the spacing member to bony structures.Spacer body 532 further includes retention aperture 542 and anattachment feature 544. Supplementary plate 536 is sized and shaped tofit congruently against an anterior aspect of spacer body 532 and flange534, such that the plate overlaps a significant portion of each fixationaperture 538. Thus, supplementary plate 536 functions as an anti-backoutmechanism, physically preventing fixation members 540 from withdrawingfrom fixation apertures 538. Supplementary plate 536 further includesretention aperture 548, through which retention member 550 may pass tobe secured into retention aperture 542 on the spacing member. Anattachment feature 544 may be disposed on spacing member 530 to providea place for temporary attachment of instruments such as an implantinsertion tool, among others.

Referring to FIG. 23, an anterior view shows spacing member 460implanted in a tibiotalar joint, with a compression bolt system 560passing through the fixation aperture 468, and anchoring the spacingmember and compression bolt between first and second exterior bonesurfaces on the tibia and the talus. Compression bolt system 560includes standoff 562, compression bolt 564, tab 566, plus extendedcortical washer 568. Standoff 562 may be shorter in length than otherstandoff disclosed herein, and extended cortical washer 568 may belonger than other cortical washers. Cortical washer 568 includes anelongated tubular body 570, rim 572, and annular shoulder 574 which isshaped to retain the head of the compression bolt 564. The extendedlength of the cortical washer body 570 may provide protection betweenthe compression bolt 564 and the fixation aperture 468. In anotherembodiment, the tubular body of the cortical washer may be shorter, andthe standoff may be longer, wherein the standoff extends through thefixation aperture 468 when spacing member 460 and the compression systemare implanted together.

A lateral view in FIG. 24 shows spacing member 530 with supplementaryplate 536 implanted in a tibiotalar joint, with a compression boltsystem 230, and a supplementary screw 340, implanted to extend throughthe window 533. The compression bolt system, supplementary screw, plusfour fixation members in the form of bone screws provide secure fixationof the system in the tibia and talus. Additionally, the compression boltsystem 230 provides compression for increased stability between thetibia and talus.

In one example of an implantation procedure for spacing member 530, itis inserted first into the prepared space between the tibia and talus,from an anterior approach. Next, using guide system 300 as set forthabove, the guide wire is inserted along a single trajectory from thetibia exterior surface through the talus to the sinus tarsi. The reameris used to create a bone bore through the tibia and talus along thetrajectory, and standoff 232 with rotatable tab 236 is inserted into thebore. Contact of the tab 236 with the calcaneus or other tissue adjacentthe sinus tarsi may trigger deployment of the tab 236 from the insertionconfiguration to the deployed configuration. Cortical washer 168 isplaced at the proximal opening of the bone bore in the tibia, and thecompression bolt is inserted and engaged with the standoff to providecompression between the bolt head/cortical washer combination, whichbear on the exterior surface of the tibia, and the tab 236, which bearson the exterior surface of the talus. Once the compressive force isapplied and the joint is immobilized, the fixation members 540 may bedriven through the fixation apertures into the tibia and talus, and thesupplementary plate 536 attached to the spacing member 530 to preventscrew backout. The supplementary screw 340 may be driven into positioneither before or after securing the spacing member 530 with the fixationmembers 540. In an alternative embodiment, the supplementary screw maybe replaced with a second compression bolt system.

The spacing members disclosed herein may implanted via anterior orlateral access. If previous procedures have resulted in several anteriorincisions, the lateral approach may be preferred to avoid woundcomplication. If a lateral approach is chosen, a fibular osteotomy maybe performed to allow access to the joint. Joint surfaces may beresected or shaped to prepare for the spacing member. The spacing memberis implanted in the prepared area, and then the compression system isimplanted as set forth previously. Obviously, during positioning of theguide system 300 to determine the trajectory for the standoff and bolt,the trajectory must be oriented to pass through the window or fixationaperture of the selected spacer. Any of the spacing members disclosedherein may be stabilized with one or two compression bolt systemspassing through the central window, or through other apertures in thespacer. Additional fixation members passing through apertures in thespacer body and/or flanges may provide added securement and stability.Also, any spacing member disclosed herein may be implanted with bonegraft material filling the spacer window.

It is appreciated that the various features of the spacing membersdisclosed herein may be mixed and matched to provide to form a varietyof other alternatives. The spacing members may be flat, anatomicallycurved, wedge-shaped for deformity or leg length correction, and/orinclude teeth or other bone engagement features as set forth previously.Attachment features such as flanges, bolt and/or screw apertures, andinstrument connection features may be included on any of the spacingmember. The spacing members disclosed herein may include any suitablebiocompatible material including, but not limited to: plastics includingPEEK, carbon fiber reinforced PEEK, glass filled PEEK, UHMWPE,polyurethane, PEKK, and PET; metals and metal alloys including titanium,titanium alloys, stainless steel, cobalt chrome, tantalum, and barium;ceramics including those including alumina, zirconia, zirconium, andsilicon nitride; pyrolitic carbon; and coatings includinghydroxyapatite, porous titanium, silicon nitride, titanium carbide, andtitanium nitride.

Ankle arthroplasty systems which may utilize compression bolt fixationas disclosed herein are shown in FIGS. 25-28. FIG. 25 shows a frontassembled view of an ankle arthroplasty system 600, while FIG. 26 showsan exploded isometric view. Ankle arthroplasty system 600 includestibial subsystem 602 and talar subsystem 604. Tibial subsystem 602includes a tibial plate 606, tibial bearing insert 608, tibialcompression bolt 610, and cortical washer 612. When properly implantedin the prepared distal end of a tibia, the tibial compression bolt 610may be actuated to provide a selected level of compression between thetibial plate and the head of the compression bolt, which may be retainedin the cortical washer. Talar subsystem 604 includes talar plate 614,talar anchor 616, and talar compression bolt 618, which is not visiblein FIG. 25. Talar anchor 616 further includes standoff 620 and anchoringtab 622. Standoff 620, which may also be referred to as a sleeve,coaxially receives a portion of talar compression bolt 618. When talarsubsystem 604 is properly implanted on a talus, talar compression bolt618 may be actuated to provide a selected level of compression betweenthe talar plate and the talar anchor. As seen in FIG. 25, the subsystems602, 604 are advantageously implantable along a single trajectoryextending through the tibia and talus, which may result in a faster andsimpler implantation procedure than required for other anklearthroplasties.

Tibial plate 606, tibial bearing insert 608 and talar plate 614 may bedescribed as a mobility structure, for when they are implanted between atibia and a talus they are configured to provide relative motion betweenthe tibia and the talus across the tibiotalar joint. In the embodimentseen in FIGS. 25-28, tibial plate 606 has a polygonal shape which isapproximately rectangular, having a superior side 630, an inferior side632, an anterior end 634, a posterior end 636, a medial end 638 and alateral end 640. Tibial plate superior side 630 includes a substantiallyplanar bone-engaging surface 642, on which are formed a plurality ofteeth 644 configured to penetrate the adjacent bone and prevent rotationof the plate. An angled lumen 646 extends between the superior andinferior sides, encircled by a collar 648 which projects at an anglefrom the superior side. The lumen 646 and collar 648 are sized andangled to receive the compression bolt at a selected angle. The collar648 is threaded to threadably engage a distal portion of the compressionbolt 610 and to engage with instrumentation as needed. Collar 648 may bereferred to as a sleeve, as it coaxially receives a portion of thecompression bolt 610. The inferior side 632 includes a raised rim 650which forms a boundary around a recess 652, into which a protrudingportion of the bearing insert is shaped to fit.

Bearing insert 608, which may be described as an articular insert, issized and shaped to fit into the recess of the tibial plate withsufficient clearance for a snap-fit connection. The outer perimeter ofthe bearing insert matches the outer perimeter of the tibial plate, suchthat when they are fitted together relatively smoothly continuousanterior, posterior, medial and lateral sides are formed. The insertincludes a superior side 654, which further includes a protrudingportion 656 surrounded by a stepped-down rim 658. Thus, when thesuperior side 654 of the insert 608 is urged against the inferior side632 of the tibial plate 606, the protruding portion 656 complementarilyfits into the recess 652, and the raised rim 650 complementarily fitsagainst the stepped down rim 658. A blind hole 660 extends into thebearing insert 608 from the superior side 654, positioned to line upwith the lumen 646 and receive a portion of the tibial compression boltwhen implanted. An inferior side 662 includes a tibial bearing surface664 which may be shaped to complementarily articulate with a talarbearing surface formed on the talar plate. The tibial bearing surface664 is concavely curved between an anterior 666 and posterior 668 end,and is also concavely curved between a medial 670 and a lateral 672 end.The shapes and radii of the bearing surface curves may vary to meetpatient anatomical constraints, meet patient motion needs, and/or tobest replicate natural ankle articulation. A thickness, or height h ofthe bearing insert is measured perpendicular relative to the superiorside 654, and varies across the insert in accordance with the curvatureof the bearing surface, and may also vary to provide deformitycorrection or leg length adjustment as needed. The bearing insert 608may include a biocompatible plastic material, such as PEEK, carbon fiberreinforced PEEK, glass filled PEEK, UHMWPE, polyurethane, PEKK, and PET,among others.

Talar plate 614 has a superior side 680 and an inferior side 682, and agenerally irregular perimeter which has an anterior end 684, a posteriorend 686, a medial end 688, and a lateral end 690. The perimeter may beshaped to conform to the superior side of the talus or in someembodiments may be more artificially shaped. The inferior side 682 maybe shaped to complementarily fit over the talus superior surface. Atalar angled lumen 692 extends through the plate between the superiorand inferior sides, and is encircled by a collar 694 which protrudesfrom the inferior side 682. The collar 694 further includes an annularshoulder 695, which retains a head 619 of the talar compression bolt 618when assembled. A plurality of teeth 696 also protrude from the inferiorside to provide stabilization and anti-rotational support to the plate614. In other embodiments of the invention, keels, ridges, posts, pegsor other bone-engagement features may be included in place of or inaddition to teeth 644 and 696. The superior side 680 includes a talarbearing surface 698, which is shaped to bear against the tibial bearingsurface 664. The talar bearing surface 698 is convexly curved betweenthe anterior 684 and posterior 686 end, and is also convexly curvedbetween a medial 688 and a lateral 690 end. The shapes and radii of thebearing surface curves may vary to meet patient anatomical constraints,meet patient motion needs, and/or to best replicate natural anklearticulation.

It is appreciated that in this and other embodiments of the invention,the relative footprint, lengths, widths, heights and shapes of theplates 606, 614 and insert 608 may vary as needed to fit patient anatomyand/or desired correction; for example, a medial end may be longer thana lateral end or the height of the insert or plates may vary as needed.Similarly, the specific curvatures of the bone-engaging and bearingsurfaces may vary to suit patient anatomy and mobility needs. Forexample, the tibial plate may be curved while the talar plate isgenerally planar, and vice versa. Also, in other embodiments, the tibialplate may include the tibial bearing surface, while the insert includesthe talar bearing surface. In yet other embodiments, the tibial andtalar plates may include the tibial and talar bearing surfaces,respectively, and no separate insert may be included. The tibial andtalar plates disclosed herein may include any biocompatible metal ormetal alloy, including but not limited to: titanium, titanium alloys,stainless steel, cobalt chrome, tantalum, and barium. The plates couldalso include biocompatible plastic material, such as PEEK, which may befilled. The bone-facing surfaces of the tibial and talar plates mayfurther include coatings or treatments including but not limited to:hydroxyapatite, porous titanium, silicon nitride, titanium carbide, andtitanium nitride.

Referring specifically to FIG. 27, a cross-sectional anterior view of anassembled configuration of arthroplasty 600 is shown. Tibial compressionbolt 610 extends between cortical washer 612 and tibial plate 606, andis threadably engaged in collar 648 of the tibial plate. When tibialcompression bolt 610 is rotated, the distance between the corticalwasher 612 and tibial plate 606 may be adjusted to provide a selectedlevel of compression between the cortical washer 612 and the tibialplate 606. Bearing insert 608 is snap-fit into tibial plate 606. Talarcompression bolt 618 extends between talar plate 614 and talar anchor616, and is threadably engaged in the standoff 620 of the talar anchor618. When talar compression bolt 618 is rotated, the distance betweenthe talar anchor 618 and talar plate 614 may be adjusted to provide aselected level of compression between the anchoring tab 622 and thetalar plate 614. Tibial bearing surface 664 and talar bearing surface698 are positioned to articulate relative to one another.

FIGS. 29-33 illustrate methods and instruments for preparation andimplantation of ankle arthroplasty system 600. Referring to FIGS. 29Aand 29B, an ankle arthroplasty guide system 700 is shown in assembledand exploded views, the modular system including talar guide 702,upright 704, guide arm 706, sleeve 708, sinus tarsi guide 710, andcutting guide 712. The cutting guide can come in a variety of heights,the chosen height depending on the height h of the bearing insert to beimplanted. The upright 704 and guide arm 706 together form a drill guide714. To prepare a tibiotalar joint for an arthroplasty implantation, ananterior incision is made and minimal cartilage is removed from thesuperior side of the talus to create room for the talar guide. The talarguide 702 is inserted and positionally adjusted until it rests in thesame position preferred for the talar plate of the implant. The talarguide may be attached to a framework or table, or otherwise stabilizedto hold the preferred position. A targeting arm 716 of the sinus tarsiguide is inserted into the sinus tarsi and the sinus tarsi guide 710 iscoupled to the talar guide. The drill guide 714 is coupled to the talarguide 702. In one embodiment, the couplings are all fixed andnon-rotatable so that the sinus tarsi guide, drill guide 714 and cuttingguide 712 may all be coupled to the talar guide 702 in specific fixedrelationships. In other embodiments, one or more of the couplings may beadjustable.

The sleeve 708 is inserted into the drill guide 714. At this point, asillustrated by the dashed line in FIG. 29A, a single straight trajectorymay pass longitudinally through the sleeve, through an opening 726 inthe talar guide 702, to a targeting point 720 on the sinus tarsi arm716. This allows for placement of the tibial and talar plate anchoringsystems along a single trajectory, and provides the potential for futureconversion from arthroplasty to fusion by removal of the arthroplastysystem 600 and replacement with a compression bolt system such as system100, 160, 180, 230, or 250, for example. A guide wire 722 is insertedthrough sleeve 708 and inserted partially through the tibia. Insertionis temporarily stopped when a marking on the guide wire 722 lines upwith the top of the sleeve 708. Next, the cutting guide 712 is placed onthe talar guide 702. An oscillating saw or other cutting means is usedto remove tibial bone adjacent to the tibial guide, guided by slots 724on the cutting guide 712. After the indicated tibial bone is removed,the cutting guide 712 is removed, and insertion of the guide wire 722can continue. As seen in FIG. 30, the guide wire 722 is inserted alongthe trajectory through the remainder of the tibia, through the opening726 in the talar guide, and through the talus to the targeting point 720on the sinus tarsi arm 716. The sleeve 708 and drill guide 714 may beremoved, and a reamer (not shown) is inserted over the guide wire toream a continuous bore through the tibia and talus, stopping when thereamer enters the sinus tarsi. The talar guide 702, reamer and guidewire 722 are removed, leaving the joint area prepared for implantationof the arthroplasty system. FIG. 31 illustrates the prepared area, whichincludes a first or tibial bone bore 730, a second or talar bone bore732, and tibial resection 734. As set forth previously, the first 730and second 732 bone bores follow a single straight trajectory throughthe tibia and talus. In the example shown, the tibial bone bore isnon-parallel with the intramedullary canal of the tibia.

After preparation of the joint area, a trial or trials may be insertedinto the tibial resection to determine the proper size and configurationfor the tibial plate, the talar plate, and the bearing insert. FIG. 32Aillustrates an exemplary trial 740 mounted on an inserter 742. Trials ofvarious sizes and shapes may be inserted until the optimal configurationof tibial plate, bearing insert, and talar plate is determined. A tamp744 including a handle 746 and a threaded tip 748 is illustrated in FIG.32B.

FIG. 33 illustrates a lateral isometric view of ankle arthroplastysystem 600 implanted into a prepared space in an ankle. With referenceto FIGS. 26, 27 and 31-33, a method for implantation of system 600 isdescribed. Talar anchor 616, with anchoring tab 622 in an insertionconfiguration, is threaded onto the tamp tip 748, and inserted throughthe tibial and talar bone bores, into the sinus tarsi. When anchoringtab 622 encounters the calcaneus, it rotates into the deployedconfiguration. The surgeon may pull back slightly on the tamp handle 746to seat the anchor tab 622 against the inferior surface of the talus andfeel that the tab is deployed. The tamp 744 is unthreaded and removed.

The talar plate 614 is inserted next, and positioned over the talus sothat the protruding collar 694 fits into the opening into the talar bonebore and the angled lumen 692 is continuous with the bone bore. Thetalar compression bolt 618 is fitted onto a bolt driver (not shown, butmay be the same as bolt driver 324) and inserted through both bonebores, through the angled lumen 692 and coaxially received into thestandoff portion 620 of the talar anchor 616. The head 619 of thecompression bolt 618 is retained by the annular shoulder 695 of thetalar plate 614. The compression bolt 618 is threadably engaged with thestandoff 620 and selectively tightened until a preferred level ofcompression is reached between the talar plate 614 and the anchoring tab622. During compression, the teeth 696 will engage in the adjacent talarsurface.

The tibial plate 606 is inserted into the tibial resection, and thethreaded tamp tip 748 is threadably engaged in the tibial plate collar648. The tamp is pulled proximally to seat the tibial plate teeth 644into the resected tibial surface. The tamp 744 is unthreaded andremoved. The cortical washer 612 and tibial compression bolt 610 areimplanted; the cortical washer 612 is fitted into the proximal openingof the tibial bone bore where it may congruently bear against theexterior surface of the tibia. The bolt 610 is inserted through thewasher, and a washer shoulder 613 retains the bolt head 611. The bolt610 is coaxially received in the tibial plate collar 648, the boltthreads are engaged with the tibial plate collar threads, and the boltdriver such as driver 324 is used to tighten the bolt. As the bolt istightened, the distance between the cortical washer 612 and tibial plate606 decreases, providing compression. The bearing insert 608 in insertedbetween the tibial plate 606 and the talar plate 614, and snapped intothe tibial plate with the protruding portion 656 of the insert fittinginto the recess 632 of the tibial plate.

In another embodiment, a screw may be used instead of the talaranchor/bolt combination to attach the talar plate 614 to the talus. Inthis embodiment, no hardware is positioned in the sinus tarsi. The screwis inserted through the angled lumen 692 and threaded into the tibialbone bore. The screw head is retained by the annular shoulder 695 of thetalar plate 614.

In yet another embodiment, a retrograde bolt may be used instead of thetalar anchor/bolt combination to attach the talar plate 614 to thetalus. A bolt may be introduced retrograde through the sinus tarsi, intothe tibial bone bore and engaged with the threaded tibial plate collar648. The bolt head is retained in the sinus tarsi by the distal openingof the tibial bone bore. In this embodiment, no opening in the superioror bearing side of the talar plate is required.

Arthroplasty system 600 may be converted to an arthrodesis system ifdesired. A spacer shaped to occupy the footprint and height of thetibial plate, bearing insert, and talar plate may be inserted to replacethose components, and a single compression bolt, passing through thespacer window, may connect to the talar anchor to provide compressionacross the joint and provide fusion.

FIGS. 34A-34E illustrates several views of a conversion spacer 750, andFIG. 34F illustrates tibial plate 606, bearing insert 608, and talarplate 614 for comparison. Conversion spacer 750 includes spacer body 752through which extends spacer window 754. An anterior side 756 includes aplurality of fixation apertures 758. A superior, or tibial surface 760is generally flat, shaped to complementarily fit into the tibialresection 734 seen in FIG. 31. An inferior, or talar surface 762 isanatomically shaped to complementarily fit over the talus, similar toinferior surface 682 of talar plate 614. An overall height, measuredfrom the talar surface 762 to the tibial surface 760, may fill thetibial resection 734 and/or provide deformity correction or leg lengthdiscrepancy correction as needed. As with other spacer members disclosedherein, conversion spacer may be angled or wedge-shaped in any directionfor deformity correction or leg length discrepancy correction as needed.

With reference to FIGS. 26, 31-33 and 35-36, a method for conversionfrom ankle arthroplasty to arthrodesis is described. The ankle joint isaccessed from an anterior approach, and bearing insert 608 is removed.The tibial compression bolt is accessed on the medial side of the tibia,unscrewed from the tibial plate 606 using a driver such as driver 324,and the cortical washer 612 and tibial compression bolt are removed. Anosteotome may be used to loosen the tibial plate, and the tibial plate606 is removed anteriorly. The talar compression bolt 618 is unscrewedand removed. The talar plate 614 is loosened, and removed. Talar anchor616 does not have to be removed; it may remain anchored in the sinustarsi and form the anchor for the arthrodesis system. However, ifdesired, the anchor tab 622 may be rotated into the insertionconfiguration, and the threaded tamp 744 used to remove the anchorthrough the medial tibial opening.

Referring to FIGS. 35 and 36, with all arthroplasty components removedexcept the talar anchor 616, conversion spacer 750 may be inserted intothe resected area 734. Bone graft material may be inserted into window754 and spacer 750 is inserted into the resected area and fitted overthe talus. A compression bolt 764, which is of sufficient length to spanfrom the talar anchor 616 to the medial tibial opening, is inserted witha cortical washer 612 and coaxially engaged with the talar anchor 616.Compression bolt 764 is tightened until the preferred level ofcompression across the joint is reached, substantially preventingrelative motion between the tibia and the talus. Supplementary fasteners766 are installed through the fixation apertures 758 as desired foradditional fixation. In place of, or in addition to, the fasteners 766,other supplementary screws or bolts may be implanted, similar to thefusion embodiments seen in FIGS. 17 and 24.

Another embodiment of an ankle arthrodesis device includes anintramedullary nail that is anchored via a toggle or nut on theunderside of the talus. Referring to FIG. 37, bone fixation system 780includes intramedullary nail 782 and anchor 784. The intramedullary nail782 is introduced antegrade from the proximal end of the tibia, thusavoiding both retrograde insertion, and placement across the subtalarjoint. The anchor 784 may be a nut or a toggle and may incorporate anyof the toggle anchor features as set forth above with reference to FIGS.6-11D. The intramedullary nail 782 may further include a standoff and acompression bolt, as set forth above at least with reference to FIGS.2-11D, to provide compression between the anchor and a proximal end ofthe intramedullary nail at the proximal end of the tibia. This system780 may provide tibiotalar fusion without relying on poor bone stock inthe talus, such as may occur after a failed arthroplasty. Bone fixationsystem 780 may be implanted in combination with any of the spacingmembers disclosed herein to together provide compression and structuralload-bearing support. In another embodiment, an arthroplasty systemdisclosed herein may also be secured with intramedullary nail 782 andanchor 784.

The present invention may be embodied in other specific forms withoutdeparting from its spirit or essential characteristics. It isappreciated that various features of the above-described examples can bemixed and matched to form a variety of other alternatives. By way ofnon-limiting example, any of the compression systems disclosed hereinmay be implanted in combination with any of the spacers. It is alsoappreciated that any of the compression systems and/or spacers and/ormobility structures may be configured to provide fusion or motion ofother joints, including at least those of the foot and wrist. Any of thecompression bolt systems may be configured to compressively join twobones or bone portions together. As such, the described embodiments areto be considered in all respects only as illustrative and notrestrictive. The scope of the invention is, therefore, indicated by theappended claims rather than by the foregoing description. All changeswhich come within the meaning and range of equivalency of the claims areto be embraced within their scope.

The invention claimed is:
 1. A method for fusing a tibio-talar jointbetween an inferior end of a tibia and a superior side of a talus, thetalus having a sinus tarsi adjacent to an inferior side of the talus,the method comprising: inserting an intramedullary nail into the tibiaalong a superior-inferior longitudinal axis, the intramedullary nailhaving a proximal end and a distal end and a nail body extendinglongitudinally therebetween along a nail axis, an external diameter ofthe nail body perpendicular to the nail axis, and an anchor rotatablyattached to the distal end of the intramedullary nail; positioning thenail body to intersect the inferior end of the tibia; extending the nailbody across the tibio-talar joint; inserting the intramedullary nail toextend through the talus along the superior-inferior longitudinal axis,the nail body intersecting the superior side and the inferior side ofthe talus; positioning the distal end of the intramedullary nail toproject into the sinus tarsi; and rotating the anchor to extendtransverse to the superior-inferior longitudinal axis and protrudebeyond the nail body external diameter.
 2. The method of claim 1,wherein the anchor has a first end and a second end and a lengthextending therebetween, the method further comprising rotating theanchor so that the anchor length is coaxial with the nail body.
 3. Themethod of claim 2, further comprising positioning the anchor first endwithin the nail body.
 4. The method of claim 2, wherein the length ofthe anchor is greater than the nail external diameter, wherein rotatingthe anchor to extend transverse to the superior-inferior longitudinalaxis further comprises positioning the first and second ends of theanchor to protrude beyond the nail body external diameter.
 5. The methodof claim 4, wherein the intramedullary nail further comprises a pair ofextensions projecting longitudinally from the distal end and a gapformed between the pair of extensions, wherein rotating the anchorfurther comprises rotating the first end from a position in the gap to aposition outside the gap.
 6. The method of claim 5, wherein a pinextends between the pair of extensions to define an axis of rotationperpendicular to the nail axis, wherein rotating the anchor furthercomprises rotating the anchor about the axis of rotation.
 7. The methodof claim 1, wherein a calcaneous is inferior to the talus, whereinrotating the anchor further comprises contacting the calcaneous with theanchor, wherein the contact with the calcaneous urges the anchor torotate to extend transverse to the superior-inferior longitudinal axis,and wherein the anchor is free from contact with the calcaneous when theanchor is transverse to the superior-inferior longitudinal axis.
 8. Themethod of claim 1, wherein rotating the anchor to extend transverse tothe superior-inferior longitudinal axis comprises rotating the anchor toextend approximately perpendicular to the superior-inferior longitudinalaxis.
 9. The method of claim 1, wherein the intramedullary nail includessurface treatments to promote bone engagement.
 10. The method of claim1, further comprising positioning a spacer between the tibia inferiorend and the talus superior side, the spacer comprising a bore, andextending the nail body through the spacer bore.
 11. The method of claim1, wherein the nail body comprises a standoff comprising the distal endand a compression bolt comprising an elongated body terminating in theproximal end, the method further comprising telescopically engaging thestandoff with the elongated body of the compression bolt to change adistance between the anchor and the proximal end.
 12. The method ofclaim 11, wherein the standoff includes an opening transverse to thenail axis, the method further comprising implanting a supplementaryscrew to extend through the opening to stabilize the nail body.